Chapter 23Rural and Migrant HealthCopyright © 2015, 2011, 20.docx

Chapter 23
Rural and Migrant Health
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders,
an imprint of Elsevier Inc.
Rural Populations
The largest rural population in history of United States is now.
75% of counties are classified as rural; they contain only 20%
of the U.S. population
Number/size of rural counties are highest …
in the South (35%)
in the Midwest and West (23%)
in the Northeast (19%)
Census data
20% of nation’s children under 18
15% of nation’s elderly
More than 50% of nation’s poor
2
Rural Populations (Cont.)
Economic base is shifting
Agriculture is the “food and fiber system”
All aspects of agriculture (core materials to wholesale and retail
and food service sectors) are included

Poverty in rural areas greater than in urban areas
3
Rural Populations (Cont.)
Poverty continues to be greater in rural America than in urban
areas.
Aging-in-place, out-migration of young adults, and immigration
of older persons from metro areas.
Greater diversity among residents: a country of immigrants
historically and today.
Health disparities exist—rural population more likely to be
older, less educated, live in poverty, lack health insurance, and
experience a lack of available health care providers and access
to health care
4
Health Disparities Among Rural Americans
Only 10% of U.S. physicians practice in rural areas
Ratio of physicians in rural population is 36:100,000 (nearly
double in urban settings)
More often assess their health as fair or poor
More disability days resulting from acute conditions
More negative health behaviors (untreated mental illness,
obesity, alcohol, tobacco, and drug use) that contribute to
excess deaths and chronic disease and disability rates

Higher number of unintentional injuries
5
Defining Rural Populations
Population size
Rural = towns with population of less than 2500 or in open
country [farm/nonfarm]
Density
Rural = fewer than 45 persons per square mile
Frontier = less than 6 people per square mile
6
Defining Rural Populations (Cont.)
The Rural-Urban Continuum uses population and adjacency to
metropolitan areas
Core Based Statistical Areas (CBSAs)
Metropolitan areas = county with at least one urbanized area of
50,000 or more people
Micropolitan area = area contains a cluster of 10,000 to 50,000
persons
Outside CBSAs = noncare areas
7

Describing Rural Health and Populations
Differ in complex geographical, social, and economic areas
Disparities include key indicators of health:
Employment
Income
Education
Health insurance
Mortality
Morbidity
Access to care
8
Rural Health Disparities: Context and Composition
Context: characteristics of places of residence
Geography, environment, political, social, and economic
institutions
Composition: collective health effects that result from a
concentration of persons with certain characteristics
Age, education, income, ethnicity, and health behaviors
– Braveman (2010)
9

Context: Health Disparities Related to Place
A downward spiral may exist:
ient
continues
10
Context: Health Disparities Related to Place (Cont.)
Access to health care (#1 priority)
Fewer primary care physicians
General health services lacking
Health insurance coverage …
Varies according to race and ethnicity;
age and residence (rural or urban)
Influences health patterns
May create financial barriers to health care
11
Composition: Health Disparities Related to Persons
Income and Poverty
One of the most important indicators of the health and well-
being of all Americans, regardless of where they live.

Regional differences—highest in the South
Racial and ethnic minorities—rates among rural racial
minorities two to three times higher than for rural whites
Family composition—female-headed families have highest rates
Children—among the poorest citizens in rural America
12
Composition: Health Disparities Related to Persons (Cont.)
Health risk, injury, and death
Higher rates of obesity, smoking, sedentary lifestyles, alcohol
use, firearms usage, suicide, vehicular accidents; lower rates of
seat belt use
Risk factors
Age, education, gender, race, ethnicity, language, and culture
Education and employment
Occupational health risks
Perceptions of health (gender, race, ethnicity)
13
Agricultural Workers
Accidents and injuries caused by:
Environmental conditions
Geographic isolation and working alone
Use of agricultural machinery
Delayed access to emergency or trauma care
Acute and chronic illnesses:

Musculoskeletal discomfort, acute and chronic respiratory
conditions, hearing loss, hypertension
Chemical exposure (pesticides, herbicides, etc.)
Secondary conditions related to demanding farm work
14
Migrant and Seasonal Farm Workers (MSFW)
Health Disparities
Poorest health and the least access
Low income and migratory status
Cultural, linguistic, economic, and mobility barriers
Minimal or no preventive care
Mobile clinic sites form a central link to health services
Migrant Health Program (MHP) bases services on enumeration
of MSFW
Migrant and Seasonal Farm Worker Enumeration Profile Study
(MSFWEPS) (2000)
15
“Thinking Upstream”
Concepts applied to Rural Health
Attack community-based problems at their roots
Emphasize the “doing” aspects of health
Maximize the use of informal networks

16
Rural Health Care Delivery System
Health care provider shortages
Rural shortages likely to become worse
Need to “grow their own”
Telemedicine
Cost-effective alternative to face-to-face care
Telehealth includes telephones, fax machines, email, and remote
monitoring
Telemedicine permits two-way, real-time, interactive
communication between patient and provider
17
Rural Health Care Delivery System (Cont.)
Managed care in the rural environment
Possible benefits:
Potential to lower primary care costs
Improve the quality of care
Help stabilize the local rural health care system
Risks
Probable high start-up and administrative costs
Volatile effect of large, urban-based, for-profit managed care
companies

18
Community-Based Care
A myriad of services provided outside the walls of an institution
Home health and hospice care, occupation health programs,
community mental health programs, ambulatory care services,
school health programs, faith-based care, elder services (adult
day care)
Community participation in decisions about health care services
Focus on all three levels of prevention
An understanding that the hospital is no longer the exclusive
health care provider
19
Home Care and Hospice
Nurse case management and development of local resources
Often hospital based in rural areas
Use county extension services as a bridge for outreach services
Improve home care for these patients and provide support for
their families
A partnership between the public health nurse and county
extension service could provide support, as well as information
groups and caregiving classes, for the important informal
provider network.

20
Faith Communities and Parish Nursing
A strong sense of community, family life, and religious faith
Integrating nursing expertise and faith-based knowledge to
provide holistic care to members of congregations
Involved in case management and coordination of services
Collaboration with other organizations to extend limited rural
community health resources
21
Informal Care Systems
Evolve from self-reliance and self-help traits of rural residents
Include people who have assumed the role of caregiver based on
their individual qualities, life situations, or social roles
Provide direct help, advice, or information
Need to identify and combine informal services with formal
systems
22

Rural Public Health Departments
Public health nurses are often the core providers of public
health services in rural areas.
Collaboration of services is key—need to develop partnerships
with other heath provider agencies.
Environmental health, maternal and child health, and
communicable disease control are the three highest-priority
programs.
23
Rural Mental Health Care
Lack of specialized mental health providers in rural areas.
Most services provided by primary care providers without
adequate preparation or support.
Perceived stigma prevents individuals from seeking mental
health services.
24
Emergency Services
Getting patients from the place of injury to the trauma center
within the “golden hour” is frequently not possible because of
distance, terrain, climatic conditions, and communication
methods.

25
Emergency Services (Cont.)
Challenges faced by rural EMS systems
Shortage of volunteers and lower levels of training
Training curricula that often do not reflect rural hazards (e.g.,
farm equipment trauma)
Lack of guidance from physicians
Lack of physician training and orientation to EMS
Also contributing to difficult public access for emergency care:
Low population density
Large, isolated, or inaccessible areas
Sever weather
Poor roads
Lower density of telephone/communication methods
26
Emergency Preparedness in Rural Communities
Challenges in rural areas:
Resource limitation
Human, financial, and social capital
Separation and remoteness
Longer response times
Low population density
Impacts funding

Communication
Warning systems often absent or neglected in remote areas;
burden on individuals
27
Legislation and Programs Affecting Rural Public Health
Programs that augment health care facilities and services
Community Health Centers (CHC) program
Migrant Health Clinic (MHC) program and the Migrant Health
Program (MHP)
Medicare’s Rural Hospital Flexibility (RHF) grant program
Primary care cooperative agreements
28
Rural Community Health Nursing
“CH nursing along the rural continuum”
29
Nonmetropolitan Areas
Metropolitan Areas

Rural Nursing …
… is the practice of professional nursing within the physical
and sociocultural context of sparsely populated communities. It
involves the continual interaction of the rural environment, the
nurse, and his or her practice. Rural nursing is the diagnosis and
treatment of a diversified population of people of all ages and a
variety of human responses to actual (or potential) occupational
hazards or actual or potential health problems existent in
maternity, pediatric, medical/surgical and emergency nursing in
a given rural area.
–– Bigbee (1993), Lee & Winters (2004),
Rosentahl (2005), Williams et al. (2012)
30
Characteristics of Rural Nursing
Should rural nursing practice be designated as a specialty or
subspecialty area because of factors such as isolation, scarce
resources, and the need for a wide range of practice skills that
must be adapted to social and economic structures?
31
Characteristics of Rural Nursing (Cont.)
Positive aspects
Ability to provide holistic care

Know everyone well
Develop close relationships with the community and with
coworkers
Enjoy rural lifestyle
Autonomy and professional status
Being valued by the agency and community
Negative aspects
Professional isolation
32
The newcomer practices nursing in a rural setting, unlike the
more experienced nurse, who practices rural nursing.
Somewhere between these extremes lies the transitional period
of events and conditions through which each nurse passes at her
or his own pace. It is within this time zone that nurses
experience rural reality and move toward becoming
professionals who understand that having gone rural, they are
not less than they were, but rather, they are more than they
expected to be. Some may be conscious of the transition, and
others may not, but in the end, a few will say, "I am a rural
nurse.”
– Scharff (1998, p. 38)
33
Rural Health Research
Research agendas must address:

The capacity of rural public health to manage improvements in
health
Information technology capacity in rural communities
Developing and monitoring performance standards in rural
public health
Developing leadership and public health workforce capacity
within rural public health
Interaction and integration of community health systems,
managed care, and public health in rural America
– Berkowitz, Ivory, & Morris (2002)
34
Capacity of Rural Public Health to Manage Improvements in
Health
Healthy People 2020 objectives and intervention strategies
Information Technology in Rural Communities
EHR and reimbursement
Preparedness strengthens infrastructure
Continuing education and advanced education
Telehealth impact on public health
Skills via distance learning?
Costs and infrastructure of IT?
Gaps in epidemiology and surveillance capacity?
35
Performance Standards in Rural Public Health
National Public Health Performance Standards Program
(NPHPSP) describe an optimal level of performance by public

health systems regardless of location.
Used to improve collaborations among key public health
partners, educate participants about public health, strengthen
the network of public health partners, identify strengths and
weaknesses, and provide benchmarks for public health practice
improvements
36
Leadership and Workforce Capacity for Rural Public Health
IOM report (2003)—preparing public health workforce for 21st
century
CDC Public Health Improvement Initiative (2012)—
accreditation support
Medicaid impact on interaction and integration of community
health systems, managed care, and public health
New models of health care delivery for rural and frontier areas
being tested
37
Chapter 21
Populations Affected by Disabilities

Most people whose lives do not end abruptly
will experience disability.
– Nies & McEwen (2015)
2
Doing a Self-Assessment
What comes to mind when you think of someone with a
disability?
Picture yourself as a person with a disability.
Imagine yourself as a nurse with a visible disability, or a client
receiving care from a nurse with a disability.
Think about living in a family affected by disability.
What is the experience of living with disability within your
community?
3
Definitions for Disability
Disability is the interaction between individuals with a health
condition and personal and environmental factors.
- World Health Organization, 2012
4
WHO International Classification of Functioning, Disability,

and Health
Disability is an umbrella term covering impairments, activity
limitations, and participation restrictions (individual level).
An impairment is a problem in body function or structure—
activity limitation or participation restriction (micro level).
A handicap is a disadvantage resulting from an impairment or
disability that prevents fulfillment of an expected role (macro
level).
5
Table 21-1
6CharacteristicImpairmentDisabilityHandicapDefinitionPhysical
deviation from normal structure, function, physical
organization, or development
May be objective and measurableNot objective or measurable; is
an experience related to the responses of
othersMeasurabilityObjective and measurableMay be objective
and measurableNot objective or measurable; is an experience
related to the responses of othersIllustrationsSpina bifida,
spinal cord injury, amputation, and detached retinaCannot walk
unassisted; uses crutches and/or a manual or power wheelchair;
blindness
Reflects physical and psychological characteristics of the
person, culture, and specific circumstancesLevel of
analysisMicro level
(e.g., body organ)Individual level
(e.g., person)Macro level
(e.g., societal)

6
National Agenda for Prevention of Disabilities (NAPD) Model
7
Figure 21-1 Reprinted with permission from Pope AM, Tarlov
AR, editors: Disability in America: toward a national agenda for
prevention, Washington, DC, 1991, Institute of Medicine,
National Academy Press. Copyright © 1991 by the National
Academy of Sciences. Courtesy National Academy Press,
Washington, DC.
Quality of Life Issues
Transportation to a needed service
Cost of care
Appointment challenges
Language barriers
Financial issues
Migrant/noninsured issues
8
Models for Disability
Medical model—a defect in need of cure through medical
intervention
Rehabilitation model—a defect to be treated by a rehabilitation

professional
Moral model—connected with sin and shame
Disability model—socially constructed
9
Disability: A Socially Constructed Issue
Disability is a complex, multifaceted, culturally rich concept
that cannot be readily defined, explained, or measured (Mont,
2007).
Whether the inability to perform a certain function is seen as
disabling depends on socio-environmental barriers (e.g.,
attitudinal, architectural, sensory, cognitive, and economic),
inadequate support services, and other factors (Kaplan, 2009).
10
“Medicalization” Issues
Nurse needs to differentiate …
A person who has an illness and becomes disabled secondary to
the illness
versus …
A person who has a disability, but may not need treatment
11

“Medicalization” Issues (Cont.)
Nurse’s interaction with PWD and families
Approach on an eye-to-eye level
Listen to understand
Collaborate with the person/family
Make plans and goals that meet the other’s needs and draw on
strengths and improve weaknesses
Empower and affirm the worth and knowledge of the
person/family with a disability
Promote self-determination and allow choices
Note: PWD = persons with disabilities
12
Historical Perspectives
Long history of institutionalization/segregation
Often viewed as sick and helpless
In the 20th century, special interest groups emerged to advocate
for PWD (e.g., ARC)
Tragedies include Hitler’s euthanasia program
Deinstitutionalization began in 1960s-1970s
Stereotypical images still common in literature and media; these
images influence prevailing perceptions of disability
13

Historical Context for Disability
Early attitudes toward PWD
Set apart from others
Viewed as different or unusual
Documented in carvings and writings
Infanticide or left to die (not in Jewish culture)
Viewed as unclean and/or sinful
Served as entertainers, circus performers, and
sideshow exhibitions
14
Historical Context
18th and 19th century attitudes
No scientific model for understanding and treating
Disability seen as an irreparable condition caused by
supernatural agency
Viewed as sick and helpless
Expected to participate in whatever treatment was deemed
necessary to cure or perform
Industrial Revolution stimulated a societal need for increased
education
If not third-grade level = feeble-minded
Special schools established in early 1800s
15
Historical Context (Cont.)
20th century attitudes

Special interest groups were formed
First federal vocational rehabilitation legislation passed in early
1920s
Involuntary sterilization of many with intellectual disabilities
ARC (Association for Retarded Children) began to advocate for
children with intellectual disabilities—today is Association for
Retarded Citizens
ARC is “world’s largest community-based organization of and
for people with intellectual and developmental disabilities”
(ARC, 2009)
16
20th century attitudes
One of the most horrendous tragedies under Hitler’s euthanasia
or “good death” program
Killed at least 5000 mentally and physically disabled children
by starvation or lethal overdoses
Killed 70,274 adults with disabilities by 1941
Over 200,000 people exterminated because they were “unworthy
of life”
Deinstitutionalization movement in 1960s and 1970s
Community-based Independent Living Centers established
17
Contemporary conceptualization

Stereotypical images remain common in literature and media
Population portrayed as a burden to society or from pity/pathos
or heroic “supercrip” perspectives
“just as the paralytic cannot clear his mind of his impairment,
society will not let him forget it.” (Murphy, 1990, p. 106)
Societal stigma still exists
Teasing or bullying often occurs in schools
Rehabilitation Act of 1973 and American with Disabilities Act
of 1990 prohibit “disability harassment”
18
Characteristics of Disability
Americans with Disabilities Act (ADA) of 1990 and
Rehabilitation Act of 1973 defined disability according to
limitations in a person’s ability to carry out a major life
activity.
Major life activities: ability to breathe, walk, see, hear, speak,
work, care for oneself, perform manual tasks, and learn
U.S. Census Bureau (2006) defines disability as long-lasting
physical, mental, or emotional condition that creates a
limitation or inability to function according to certain criteria.
19
Examples of Disabilities
Physical disabilities
Sensory disabilities
Intellectual disabilities

Serious emotional disturbances
Learning disabilities
Significant chemical and environmental sensitivities
Health problems
20
Measurement of Disability
Survey of Income and Program Participation (SIPP)
Functional activities
Activities of daily living (ADLs)
Instrumental activities of daily living (IADLs)
American Community Survey (ACS)
Surveys for disability limitation in six areas that affect function
or activity (sensory, physical, mental/emotional, self-care,
ability to go outside the home, employment)
Other organizations also collect disability data
21
Prevalence of Disability
In 2010, approximately 18.7% of civilian noninstitutional
population aged 5 years and older had a long-lasting condition
or disability.
Of those with a disability, 12.6% had a “severe” disability.
Prevalence varies by race, age, and gender.
It is important for health care policymakers and health care

providers to recognize that the prevalence of disability is
increasing.
22
Prevalence of Disability in Children
Approximately 15.2% of households with children have at least
one child with a special health care need (disabling condition).
– National Survey of Children with
Special Health Care Needs (2009/2010)
A disability is defined by a communication-related difficulty,
mental or emotional condition, difficulty with regular
schoolwork, difficulty getting along with other children,
difficulty walking or running, use of some assistive device,
and/or difficulty with ADLs
23
Recommendation for the Nurse
Listen to parental concerns
“Something is not right”
Establishes an important bond with parents
Nurse can serve as an intermediary
Regularly assess for key developmental milestones
Compare with predicted values
Work with team of resource providers on IEP
Be cognizant of disability within the context of culture and
aging

24
Legislation Affecting People with Disabilities
Individuals with Disabilities Education Act (IDEA) (1975);
reauthorized in 1997, 2004
Ensured a free appropriate public education (FAPE) in the least-
restrictive setting to children with disabilities based on their
needs
Parents, students, and professionals join together to develop an
Individualized Education Program (IEP), including measurable
special educational goals and related services for the child.
25
Americans with Disabilities Act of 1990 and ADA Amendments
Act of 2008
ADA: Landmark civil rights legislation that prohibits
discrimination toward people with disabilities in everyday
activities
Guarantees equal opportunities for people with disabilities
related to employment, transportation, public accommodations,
public services, and telecommunications
Provides protections to people with disabilities similar to those
provided to any person on basis of race, color, sex, national
origin, age, and religion

26
ADA (Cont.)
Refers to a “qualified individual” with a disability as a person
with a physical or mental impairment that substantially limits
one or more major life activities or bodily functions, a person
with a record of such an impairment, or a person who is
regarded as having such an impairment.
Qualifying organizations must provide reasonable
accommodations unless they can demonstrate that the
accommodation will cause significant difficulty or expense,
producing an undue hardship.
27
Americans with Disabilities Act of 1990 and ADA Amendments
Act of 2008 (Cont.)
Ticket to Work and Work Incentives Improvement Act
(TWWIIA)
Increases access to vocational services; provides new methods
for retaining health insurance after returning to work
Increases available choices when obtaining employment
services, vocational rehabilitation services, and other support
services needed to get or keep a job
Became law in 1999, amended in 2008

28
Public Assistance Programs
Cash assistance
Supplemental Security Income—SSI
Social Security Disability Insurance—SSDI
Food stamps
Public/subsidized housing
Costs associated with disability
Gaps in employment, income, education, access to
transportation, attendance at religious services
29
Health Disparities in Quality and Access
Disparities are caused by …
Differences in access to care
Provider biases
Poor provider-patient communication
Poor health literacy
Persons with disabilities experience …
Higher rates of chronic illness
Increased risks for medical, physical, social, emotional, and/or
spiritual secondary issues
People with intellectual disabilities are
Undervalued and disadvantaged

30
Systems of Support for People With Disabilities
31
Figure 21-2
The Experience of Disability
PWD may be largest minority group in the United States
Different experiences, depending on …
Temporary disability
Permanent disability from accident or disease
Disability from progressive decline of a chronic illness
Benchmark event is acceptance of the label of “disabled”
32
Children With Disabilities (CWD)
Family and caregiver responses
Redefine image and expectations for child and self
Sibling response influenced by age, coping, peer relationships,
parents, impact on family
Levels of parental adjustment
The ostrich phase

Special designation
Normalization
Self-actualization
33
Family Research Outcomes
Established various benefits, amid challenges
Families with satisfying emotional support experience fewer
potentially negative effects of unplanned or distressing events.
Parents may grieve the loss of idealized or expected child over
time.
Supportive relationship is needed.
Empowerment and enabling decision making on behalf of CWD
is important.
34
Knowledgeable Client
A person who lives with a disability commonly becomes an
expert at knowing what works best for his or her body.
35
The nurse who has information about the disability and the
available community and governmental resources.
Knowledgeable Nurse

Strategies for the CH Nurse
Do not assume anything.
Adopt the client’s perspective.
Listen to and learn from client. Gather data from the perspective
of the client and family.
Care for the client and family, not for the disability.
Be well informed about community resources.
Become a powerful advocate.
36
Dealing With Ethical Issues
Spiritual perspectives
Quality of life (QOL) and justice perspectives
Proper use of scientific advances
Self-determination, deinstitutionalization, and disability rights
37
When the Nurse Has a Disability
Education programs and employers must provide reasonable
accommodations for qualified students and nurses.
Technical aspects of nursing tend to discriminate; nursing

should emphasize “humanistic” capacities.
Type of setting influences functionability.
38
Nurses Can …
… become familiar with a variety of ethical frameworks for
decision making.
… help the patient and family access needed information to
make informed decisions.
… help educate the public on health care issues.
… participate in the development of institutional policies and
procedures related to disability.
… take a position on an ethical issue.
… work to influence government policies and laws.
39

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